Provider Demographics
NPI:1861810244
Name:GLENN, GENEVRA DIANA
Entity type:Individual
Prefix:MRS
First Name:GENEVRA
Middle Name:DIANA
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2781 W RAMSEY
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220
Mailing Address - Country:US
Mailing Address - Phone:951-849-3896
Mailing Address - Fax:951-849-0506
Practice Address - Street 1:2781 W RAMSEY
Practice Address - Street 2:SUITE 1
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-849-3896
Practice Address - Fax:951-849-0506
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11980613101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)